[Pulmonary embolism and inferior vena cava agenesis: An unusual association]. / Embolie pulmonaire et agénésie de veine cave inférieure : une association inhabituelle.

INTRODUCTION: Inferior vena cava agenesis is a rare congenital anomaly, generally associated with thrombophilic conditions, and a predisposing factor for deep venous thrombosis (DVT), rarely complicated by pulmonary embolism, in a young population with atypical clinical features and frequent absence of risk factors. CASE REPORT: We report the case of a 30-year-old woman who developed a right iliac DVT, initially presenting as a low back pain and complicated by a pulmonary embolism, 8 months after a sleeve gastrectomy. Chest CT angiography revealed abnormalities that led to the diagnosis of inferior vena cava agenesis. Thrombophilic screening showed a heterozygous prothrombin gene mutation G20210A and hyperhomocysteinemia. The patient was treated with rivaroxaban with good results after 2 years of follow-up. CONCLUSIONS: In young patients without risk factors developing a deep venous thrombosis, an inferior vena cava anomaly should be considered. Although no therapeutic consensus has been currently established, inferior vena cava agenesis seems to be associated with a high prevalence of thrombophilic disorders. Screening could be useful, particularly in patients with a thrombotic family history.

[Platypnea, orthodeoxia A report of two cases]. / Platypnée, orthodéoxie À propos de deux cas.

The plathypnea orthodeoxia syndrome is a rare condition that is characterized by dyspnea and hypoxia that occurs in the upright position and improves with recumbency. The diagnostic is often made tardively and requires the combination of two components: a mechanical one (for example a patent foramen ovale) and a kinetic one (for example COPD). This combination contributes to the blood flow through the communication. The treatment consists of closing the veno-arterial communication (in the case of a patent foramen ovale, the closing of the inter-atrial septum) (Knapper et al, 2014). In the present article, we describe two severe hypoxemic patients suffering from this syndrome. Both cases were associated with an acute pulmonary disease. A review of the literature is performed.

Levothyroxine treatment and pregnancy outcome in women with subclinical hypothyroidism undergoing assisted reproduction technologies: systematic review and meta-analysis of RCTs.

BACKGROUND Previous meta-analyses of observational data indicate that pregnant women with subclinical hypothyroidism have an increased risk of adverse pregnancy outcome. Potential benefits of levothyroxine (LT4) supplementation remain unclear, and no systematic review or meta-analysis of trial findings is available in a setting of assisted reproduction technologies (ART). METHODS Relevant trials published until August 2012 were identified by searching MEDLINE, EMBASE, Web of Knowledge, the Cochrane Controlled Trials Register databases and bibliographies of retrieved publications without language restrictions. RESULTS From 630 articles retrieved, we included three trials with data on 220 patients. One of these three trials stated 'live delivery' as outcome. LT4 treatment resulted in a significantly higher delivery rate, with a pooled relative risk (RR) of 2.76 (95% confidence limits 1.20-6.44; P = 0.018; I(2) = 70%), a pooled absolute risk difference (ARD) of 36.3% (3.5-69.0%: P = 0.030) and a summary number needed to treat (NNT) of 3 (1-28) in favour of LT4 supplementation. LT4 treatment significantly lowered miscarriage rate with a pooled RR of 0.45 (0.24-0.82; P = 0.010; I(2) = 26%), a pooled ARD of -31.3% (-48.2 to -14.5%: P < 0.001) and a summary NNT of 3 (2-7) in favour of LT4 supplementation. LT4 treatment had no effect on clinical pregnancy (RR 1.75; 0.90-3.38; P = 0.098; I(2) = 82%). In an ART setting, no data are available on the effects of LT4 supplementation on premature delivery, arterial hypertension, placental abruption or pre-eclampsia. CONCLUSIONS Our meta-analyses provide evidence that LT4 supplementation should be recommended to improve clinical pregnancy outcome in women with subclinical hypothyroidism and/or thyroid autoimmunity undergoing ART. Further research is needed to determine pregnancy outcome after close monitoring of thyroid function to maintain thyroid-stimulating hormone and free T4 levels within the trimester-specific reference ranges for pregnancy.

[The number needed to treat (NNT)]. / Le nombre de sujets qu'il est nécessaire de traiter (NST).

The number needed to treat (NNT) is a valuable information in treatment decisions. This is the result of a calculation based on published data, collected from an intervention study. NNT is the inverse of the absolute risk reduction (1/ARR) between two treatment options. It is always expressed by a value rounded up to whole numbers, between 1 and infinity, depending on the effectiveness of the new treatment being studied. The NNT is the average number of patients needed to be treated for a duration equal to the study period to achieve one additional positive response under the conditions of the study. The more the treatment will be effective, the more the NNT will be low (tending towards 1). The NNT should be calculated based on the results of a clinical study of good methodological quality, involving a well-defined and homogeneous group of patients, whose baseline risk is known and using a dichotomous endpoint (the event occurs or not). The study must have shown a statistically significant difference between the two groups. In the process of medical decision making, the NNT must be balanced with the safety profile of the treatment (represented by the number needed to harm, or NNH), the costs and stress associated with it. It is possible to calculate a NNT and its confidence interval, from the published data of a clinical study. Some authors report the NNT in the text of the publication.

Mycobacterium marinum infection causing extensive tissue destruction in a hypoxic COPD patient.

We report a skin Mycobacterium marinum infection presenting as wide ulcerative lesions of the arm (4 cm for the widest) in a hypoxic COPD patient who takes 4 mg methylprednisolone daily and higher doses during exacerbations. Diagnostic delay as well as glucocorticoid use could be responsible for the extension of the lesions. Clinical resolution occurred after three months of antibiotic therapy. Extensive ulcerative lesions are uncommon in Mycobacterium marinum infection in an immunocompetent host. This case emphasizes the potential and unusual harmful effect of long-term glucocorticoid therapy used in obstructive lung disease on the spread of Mycobacterium marinum infection.

Second primary lung malignancy in head and neck cancer patients.

INTRODUCTION: Second primary lung cancer (SPLC) is generally of poor prognosis in patients presenting with head and neck cancer. METHODS: Between January 2000 and June 2008, 39 patients with head and neck squamous-cell carcinoma (HNSCC) patients diagnosed with SPLC were included. RESULTS: Fourteen SPLC were classified as synchronous and 25 as metachronous. SPLC and HNSCC staging correlated (P=0.0496). Patients with metachronous tumor showed longer median overall survival than those with synchronous tumor (92.9 months versus 15.7 months; Hazard ratio (HR), 0.323; 95% CI, 0.042-0.559; P=0.0045). In the subgroup of 11 patients with SPLC diagnosed more than 5 years after HNSCC, prognosis was better (128.1 versus 29.7 months; HR, 0.288; 95% CI, 0.053-0.353; P<0.0001). DISCUSSION: In the present study, in contrast to the literature, improved prognosis and survival were found in the subgroup in which SPLC developed more than 12 months after initial HNSCC diagnosis, and even more specifically in that in which SPLC developed more than 5 years after initial HNSCC diagnosis. CONCLUSION: SPLC in HNSCC is generally described as unequivocally aggressive and of poor prognosis. Metachronous SPLC, however, especially when diagnosed more than 5 years after HNSCC, was clearly associated with better prognosis.

Identifying non-alcoholic fatty liver disease among asymptomatic overweight and obese individuals by clinical and biochemical characteristics.

OBJECTIVE: To determine the prevalence of liver steatosis among asymptomatic individuals attending an out-patient clinic for a problem of overweight, and to define the discriminatory value of several characteristics for predicting liver steatosis among them. DESIGN AND PARTICIPANTS: Consecutive patients Swith a body mass index (BMI) of > or =25 kg/m2 who consented to undergo liver ultrasound and blood tests were recruited for inclusion. Receiver operating characteristic (ROC) curves were generated and statistical indices of diagnostic performance and their corresponding 95% confidence intervals (95% CI) were computed. Logistic regression analyses were performed to determine whether a combination of characteristics could improve diagnostic accuracy. RESULTS: We enrolled sixty-eight subjects (mean BMI, 37.5 kg/m2), of whom 39 (57.4%) had liver steatosis on ultrasound. Logistic regression analyses indicated that only 3 variables were significantly and independently correlated with liver steatosis: female gender, low adiponectin levels, and high insulin resistance index. A composite index for predicting liver steatosis was calculated by summing the risk factors of female gender, low adiponectin, and insulin resistance index (FAIR score). The accuracy of this score was determined by ROC analysis to be 0.85 (95% CI, 0.74-0.96; P < 0.001). The presence of two or more risk factors (FAIR score > or =2) had a sensitivity, specificity, positive predictive value, and negative predictive value of 77%, 91%, 92%, and 74%, respectively. The likelihood ratio for a positive result was 8.43. CONCLUSIONS: Among asymptomatic overweight individuals attending an out-patient clinic, the prevalence of liver steatosis on ultrasound is 57%. Female gender, the insulin resistance index, and low adiponectin are significant and independent predictors of liver steatosis. A combination of these three factors allows sensitivity and specificity for non alcoholic fatty liver of 77% and 91%, respectively.

Respiratory consequences of obesity--an overview.

At the beginning of the 21st century obesity has become the leading chronic disease in the world. It is a major cause of morbidity mainly in the metabolic and cardiovascular areas. Moreover, it has progressively emerged as an important risk factor for respiratory diseases, a field that is often neglected. In this article, we reviewed the current understanding of the influence of obesity in adulthood on respiratory function, obstructive sleep apnoea-hypopnoea, obesity hypoventilation syndrome and asthma.

[Malignant peripheral nerve sheath tumor in the posterior mediastinum]. / Tumeur maligne de la gaine d'un nerf périphérique: une lésion rare du médiastin postérieur.

We report the case of a 52-year-old male patient who developed a malignant peripheral nerve sheath tumor (MPNST) localized in the posterior mediastinum. The diagnosis of this rare tumor is difficult because the clinical presentation of the benign or malignant types is often similar, i.e. elective pain and bone erosions. Similarly, radiological procedures do not always allow distinction between the two types. MNR and CT-scan are the first line procedures: they localize and characterize the lesions, and CT-scan can also be a guide for biopsies. Histological diagnosis is required, but diagnosis can be compromised by the heterogeneous nature of the tumor. Surgical treatment should be undertaken whenever possible. Survival was unusually long in our patient, more than 5 years after discovery of the MPNST. This type of sarcoma is often very aggressive with frequent development of local recurrences and metastases.

Operating characteristics of the Finapress system to predict elevated left ventricular filling pressure.

BACKGROUND: Dyspnea is a common symptom and can be caused by many different conditions. The detection of congestive heart failure (CHF) is sometimes difficult. HYPOTHESIS: The pulse amplitude ratio (PAR) measured by the Finapress procedure during a Valsalva maneuver can detect elevated left ventricular end-diastolic pressure (LVEDP) accurately over a wide range of values. METHODS: Comparison of the estimated LVEDP by PAR with the invasively measured LVEDP before and after ventriculography during coronography was made in 101 consecutive stable patients referred for chest pain and/or chronic dyspnea. RESULTS: A significant correlation was found between the catheter-measured LVEDP (range 3-40 mmHg) and the PAR (R2 = 0.70, p < 0.001). The receiver operator characteristics (ROC) of the PAR to detect an LVEDP > 15 mmHg can be considered to be excellent, with an area under the ROC curve achieving 0.92 (95% confidence interval [CI] 0.87-0.96; p < 0.001). A PAR of > 0.675 predicted the presence of an LVEDP > 15 mmHg with a sensitivity of 0.865 (95% CI 0.780-0.926) and a specificity of 0.847 (95% CI 0.730-0.928). The positive and negative LRs were 5.70 and 0.16, respectively. CONCLUSIONS: The observed likelihood ratios confirm that the PAR determined by the Finapress procedure may be a useful bedside diagnostic tool in patients with cardiac conditions.

[Hemoptysis in a young man]. / Hémoptysies chez un jeune homme.

INTRODUCTION: We describe the development of severe and recurrent alveolar hemorrhage in a 30 year old man. The patient had presented with frank hemoptysis, that recurred after an interval of 4 weeks, associated with dyspnea and severe anemia requiring transfusion. The chest x-ray and CT scan showed bilateral diffuse ground glass shadows. Fibreoptic bronchoscopy confirmed bilateral diffuse bleeding. Investigations for the common causes of diffuse alveolar hemorrhage (immunological, infective) proved to be negative on two occasions. Toxicological examination of the urine during the relapse revealed a significant level of cannabis and a trace of cocaine. The patient repeatedly denied the use of illicit drugs. CASE REPORT: Because of the general condition of this young patient a lung biopsy was performed by video-thoracoscopy. This showed evidence of diffuse alveolar damage compatible with inhalation of cocaine. Faced with these results the patient admitted that he regularly smoked "improved joints". CONCLUSION: This clinical observation emphasises that the inhalation of cocaine is a cause of diffuse alveolar hemorrhage particularly in young adults.

P0.1 during exercise in normal subjects breathing mixtures of gas with varying densities.

BACKGROUND AND AIM: The aim of the study was to re-examine the occlusion pressure measured simultaneously in the mouth (P0.1) and the oesophagus (Poes.1) during exercise in normal subjects submitted to different gas mixtures. METHODS: 7 healthy men breathing random gas mixtures containing 21% oxygen with either by 79% helium (He-O2) or sulphur hexafluoride (SF6-O2) and room-air, were studied during a steady-state 90w exercise performed on a cyclo-ergometer. Ventilatory parameters were derived from the flow signal recorded by a pneumotachograph calibrated with the different gas mixtures. Three pressure transducers (mouth, eosophageal and gastric) were checked to have iso-time identical responses up to 4Hz. P0.1, Poes.1, deltaPoes (difference in oesophageal pressure between end-inspiratory and end-expiratory levels) and deltaPdi (variation of transdiaphragmatic pressure between end-inspiratory and end-expiratory levels) were measured. RESULTS: Hyperventilation associated with a similar deltaPoes/deltaPdi but a lower P0.1/deltaPdi ratio was observed in He-O2 breathing compared to SF6-O2 and air. Variable time delays between oesophageal and mouth pressures were observed during air and SF6-O2. Whatever the condition involved, no change was detected in the shape of the inspiratory pressure during the occlusion manoeuvres. CONCLUSIONS: He-O2 breathing probably induced a change in the shape of the pressure wave later on in the inspiratory phase, making P0.1 not representing the total inspiratory drive. On the contrary in air and SF6-O2 conditions, P0.1 seemed to remain a useful tool for looking at the output of the respiratory controller.

Operating characteristics of the negative expiratory pressure technique in predicting obstructive sleep apnoea syndrome in snoring patients.

BACKGROUND: This study examines the operating characteristics of the expiratory flow response to a negative pressure (NEP) applied to the mouth in the prediction of obstructive sleep apnoea syndrome (OSAS) in snoring patients. METHODS: Two hundred and thirty eight patients with normal spirometric values were studied. Full laboratory polysomnography was performed and an NEP of -5 cm H(2)O was applied in the sitting and supine positions. RESULTS: A significant correlation was found between the degree of flow limitation measured by NEP in both positions (expressed as the percentage of the expired tidal volume over which NEP induced flow did not exceed spontaneous flow) and the apnoea-hypopnoea index (AHI). This correlation was significantly higher in the supine position (p<0.0001) where an expiratory flow limitation cut off value of >/=27.5% of the tidal volume produced a sensitivity of 81.9% and a specificity of 69.1% in predicting OSAS. CONCLUSION: These findings show that the degree of instability of the upper airway measured by NEP is correlated with the severity of OSAS. NEP had moderate sensitivity and specificity and may be useful in predicting OSAS in a clinic based population.

[Subcutaneous emphysema in a borderline patient]. / Emphysème sous-cutané et troubles de la personnalité

This report concerns a 31-year-old woman. It is an intricate case including bilateral self-induced pneumoparotitis, cervical and facial subcutaneous emphysema and limited pneumomediastinum. Besides, this borderline patient simulated asthma attacks. The clinical picture was characteristic of Munchausen's syndrome with multiple hospitalisations in various hospitals, automutilations and intentional production of physical symptoms. The diagnosis and the treatment are discussed.